Not enough primary-care doctors? Try Missouri's plan

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Everyone agrees that the United States does not have enough primary-care physicians. The Department of Health and Human Services estimates that the shortage is at least 16,000 doctors.

Various strategies have been pushed to solve the problem, such as creating medical schools that emphasize educating primary-care providers, increasing the number of residencies for medical school graduates, and expanding the number and authority of non-physician providers of primary care to include nurse practitioners, physician assistants, psychologists and pharmacists.

But these are all long-term changes to a problem that is only going to become more dire. A growing aging population will need more primary medical care. The Affordable Care Act is likely to increase the demand for primary-care doctors as insurance coverage is extended to more Americans. Some primary-care doctors, already overwhelmed by patient demand and paperwork, are creating boutique cash-only practices or are simply retiring.

So what to do? One exceedingly controversial idea has just become law in Missouri.

Missouri will allow medical school graduates to work as “assistant physicians” treating patients in underserved rural areas, even though they have not been trained in a residency program. Under the new law, an assistant physician must have passed the first two sections of the national licensing exam but not the final one.

These assistant physicians must work with a collaborating physician for 30 days and could prescribe most medications. They then may treat patients on their own if they practice within a 50-mile radius of that supervising doctor. They also must be approved by the state Board of Healing Arts, which issues medical licenses.

The Missouri State Medical Association, which represents the state's 6,500 physicians, helped draft the legislation. It argued the law was needed to address a severe shortage of health care professionals in the state.

There are many national medical groups that oppose the idea. Letting someone practice without a residency in the view of critics is to dangerously weaken professional competency.

So who will these new doctors be? Some will be graduates of medical schools who failed to get into a residency program — a growing problem as more medical schools open but more residencies do not. Others will have failed or gotten low scores on Step 1 or Step 2 of the U.S. Medical Licensing Examination on the first try. Some will have gone to non-U.S. medical schools. A few medical school grads will choose to be an assistant physician rather than enter residency.

So the bottom line is that assistant physicians are not likely to be the cream of the U.S. medical school crop. But that crop is not yielding many primary-care providers. And new residency slots are not going to open anytime soon.

The real question is, can someone who successfully got through four years of medical school, who is supervised and certified by another doctor for a month and by the state board but who is probably not near the top of his class deliver high-quality primary care?

I think we don't know. But I think it is very likely that most can. And Missouri, and other states that are considering following its lead, are right to give assistant physicians a chance. Fairly good primary care is a lot better than no care at all.

Arthur L. Caplan is the director of medical ethics at NYU Langone Medical Center in New York.

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